Clinical Risk Adjustment

Using Licensed Nurse Practitioners, SCCP performs clinical adjustment services aimed at ensuring that the health conditions and health status of health plan members are accurately documented, and that health plans are properly compensated for managing the care of its members.

Our Clinical Risk Adjustment Services include:

    • High level engagement for difficult-to-engage members.
    • Completing an accurate and substantiated clinical profile of members.
      • Verifying prior clinical diagnosis.
      • Assessing for worsening conditions.
      • Assessing for new, undiagnosed conditions.
      • Performing a review of all medications.
      • Ordering labs and diagnostic tests where necessary to confirm diagnosis.
      • Coding to clinical specificity.
      • Making referrals to primary care providers where member health conditions warrant it.

Healthcare Effectiveness Data and Information Set (HEDIS)

SCCP supports the work of health plans to improve their HEDIS scores by closing member care gaps for the following HEDIS measures:

  • Prevention and Screening
    • Breast Cancer Screening (BCS)
    • Cervical Cancer Screening (CCS)
    • Colorectal Cancer Screening (COL)
  • Behavioral Health.
    • Follow-Up After Hospitalization (FUH)
    • Follow-Up After Emergency Department Visit for Mental Health (FUM)
    • Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA)
  • Medication Management and Care Coordination
    • Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC)
  • Access/Availability
    • Adults’ Access to Preventive/Ambulatory Health Services (AAP)
    • Annual Dental Visit (ADV)
    • Prenatal and Postpartum Care (PPC)
  • Utilization
    • Child and Adolescent Well-Care Visits (W30, WCV)

We employ the following strategies to close HEDIS care gaps:

  • Reducing engagement fragmentation by creating a single touch point for HEDIS compliance outreach.
  • Providing coordinated HEDIS Compliance Support to members:
    • Scheduling HEDIS gap closure appointments (wellness visits, lab work, health screenings, etc.).
    • Appointment reminder calls.
    • Post appointment follow-up to ensure compliance.
    • Addressing barriers to HEDIS compliance (i.e., transportation).
    • Addressing member health literacy through education.
    • Addressing exclusions.
    • Making social service referral where necessary to support gap closure.
  • Encouraging at-home testing where available.
  • Using a multichannel approach to member engagement (phones, texting).
  • Offering clinical support (NPs under the supervision of a Medical Director) to close Gaps:
    • Ordering lab tests where needed.
    • Clinical engagement (wellness exams and other examinations) via onsite, telehealth, or home visits.
  • Sharing reports through a robust data integration platform.

New Member Onboarding

SCCP believes that timely and effective outreach to new members can significantly impact health outcomes and reduce the overall cost of care for health plans. Therefore, our onboarding services provide High Touch, new member engagement support.

This initial encounter with a new member is designed to start the process towards achieving high member satisfaction and retention rates, by creating a positive first impression, establishing trust, addressing questions, and educating the new member on how to access the services they need.

Onboarding services for new members include:

    • Member Welcome Encounter
      • Introduction and Welcome Call
      • Verifying or Updating Demographic Information
      • Verifying New Member Receipt of Welcoming Materials
      • Confirming PCP Assignment
      • Completing Health Risk Screening
      • Addressing New Member Questions and Concerns
    • Location of “Hard-to-Find” Members
      • Skip Tracing
      • Partnering with Community Stakeholders to Locate Members

Population Health Management

SCCP is uniquely positioned to provide comprehensive, person-centered, population health management services, for high-risk and high-cost populations. Our integrated ecological model aims at addressing the inter-relational aspects of physical, psychological, and social determinants of health status, through providing a comprehensive array of coordinated, timely, and accessible services that are culturally competent. These services are provided by Clinical Care Managers (RNs, LCSWs) with support from Navigators (CNAs, CMAs, Community Health Workers).

Our population health management services include:

    • Onboarding New Health Plan Members
    • Health Risk Screenings/Assessments
    • Care Planning
    • Health Education/Health Literacy Activities
    • Monitoring and Tracking of Treatment Adherence
    • Discharge Planning and Transition of Care Support
    • Chronic Care Management
    • Medication Management
    • Navigator Support
    • Addressing Social Determinants of Health
    • Linking Members to Community Resources
    • Appropriate Reporting

Physician Extender Services

SCCP works with physician groups (ACOs, PHOs, IPAs) and independent physicians to provide clinical care management support beyond the physician’s office. Our physician support services include:

    • Chronic Disease Self-Management Services
    • HEDIS Compliance Support
    • Monitoring and Tracking of Key Health Indicators
    • Flagging Care Gaps
    • Real-Time Alerts Regarding Member Health Status
    • Working with Members to Schedule PCP and Other Medical Appointments
    • Monitoring Attendance
    • Behavioral Change/ Compliance Support
    • Reporting

Social Determinants of Health

We recognize that health outcomes are closely linked to non-medical issues that impact access to care and member compliance. That’s why we utilize our Navigators to help members address barriers to care, basic social needs, and other challenges to their self-sufficiency, through the following:

    • Facilitating Social Service Referrals
    • Linking Members to Community Resources
    • Assisting Members to Address Language Barriers
    • Addressing Non-Emergency Medical Transportation (NEMT) Needs